VOCN 1329 Medical Surgical 1

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Chapter 52 Lower GI Tract

• VOCN 1329 Medical Surgical 1

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Constipation pg 848

• Stool becomes dry, compact and difficult to pass.
  
• Consistency of stools and the comfort with which
  they are passed are more reliable indicators than
  frequency
• Diet high in fiber--whole grains, fresh fruits,
  and uncooked vegetables form a larger residual of
  cellulose which absorbs water, increases stool
  volume and softens

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Constipation Patho

• Chronic use of laxatives or enemas may produce
  constipation because they cause a loss of normal
  colonic motility and intestinal tone. They also
  dull gastrocolic reflex

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Constipation S/S

• Bowel elimination is infrequent or irregular.
• Feel bloated, abdomen may be tympanic or
  distended and may have hypoactive bowel sounds.
• Rectal fullness, pressure and pain are
  experienced when trying to eliminate stool. What
  is passed is dry and hard. Rectal bleeding may
  occur

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Constipation

• If retained for a long time, may pass liquid
  stool around obstructive mass.
• Liquid stool results from dry stool stimulating
  nerve endings of the lower colon and rectum which
  increases peristalsis and sends watery stool from
  above

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Constipation Nursing Management

• Get a complete history, including laxative or
  enema use
• Describe bowel elimination pattern, frequency,
  overall appearance and consistency of stool,
  presence of blood, painful elimination or effort
  necessary to pass stool. Assess diet, fluid
  intake and activity level

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Constipation

• Examine anal area, looking for fissures, redness
  and hemorrhoids.
• Auscultate bowel sounds and palpate for
  distention and masses
• Inspect stool and do rectal exam if indicated
• Review nursing interventions page 850

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Teaching

• When constipation related to dietary habits,
  decreased fluid intake, stress, lack of exercise
  suggest a high fiber diet and include plenty of
  raw fruit and vegetables, whole grains and coarse
  bran and cereals
• Drink 8 or more glasses of water and fruit juice
  daily because fructose is a natural laxative.
  Exercise daily

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Teaching for Constipation

• Tell him to respond quickly to urge to defecate
  and allow time to go. Use toilet after meals when
  gastrocolic reflex is more active. Avoid
  excessive straining
• Stress that laxatives can be habit forming
  requiring more frequent use and higher doses.
  Stool softeners are safer.
• Cheese constipates, increase fiber for bulkier
  more moist stools

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High Fiber Diet to Manage Constipation

• Look at Box 52-1 pg 850 High Fiber
• Look at Box 52-1 pg 850 Low Residue Diet

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Diarrhea Pg 851

• Frequent passage of liquid or semi-liquid stool
• Results from increased peristalsis that rapidly
  moves fecal matter thru GI tract
• Causes intestinal cramping and decreases time
  water is absorbed from stool in large intestine.
  Stool is very soft or liquid
• 3 major problems can cause dehydration,
  electrolyte imbalance and vitamin deficiency

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Diarrhea S/S

• Stools are watery and frequent. In severe cases,
  blood and mucus pass with stool.
• Generally has tenesmus (urgency) and abdominal
  discomfort.
• Bowel sounds are hyperactive Skin around anus may
  become excoriated
• Should limit intake to clear liquids for 8 hrs

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Diarrhea Assessment

• Ask about eating tainted food, is anyone else
  having diarrhea. Ask about recent foreign travel)
• Taking new drugs
• Review page 851 and 852 for assessment and care

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Diarrhea

• Sudden onset of acute abdominal pain or a rise in
  temperature may indicate perforation of the bowel

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Teaching

• Teach to contact Dr. if diarrhea is prolonged or
  accompanied by severe abdominal pain, if blood or
  mucus passes with stool, if fever develops or
  urine output decreases.

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Irritable Bowel Syndrome Pg 853

• Spastic colon is not a disease but a group of
  symptoms that occur despite the absence of
  disease.
• Paroxysmal motility disorder primarily affecting
  the colon. Has alternating periods of
  constipation and diarrhea. One is usually worse
  than the other
• Most have chronic constipation with sporadic
  bouts of diarrhea

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Irritable Bowel Syndrome

• May have belching, flatulence, abdominal pain
  which may or not be relieved by defecation.
  Usually does not wake him from sleep.
• May have anxiety, insecurity, depression or anger
• Weight usually remains stable, stools usually of
  small volume, may have mucus but usually not
  blood as bowel not inflamed

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Irritable Bowel Syndrome

• Avoid food that cause discomfort or intestinal
  gas such as beans, cabbage and eat high fiber
  diet
• Most are not hospitalized.
• Teach management of constipation and diarrhea

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Inflammatory Bowel Disease Pg 854

• Chronic disorder characterized by exacerbations
  and remissions
• Ulcerative colitis and Crohns disease are
  inflammatory bowel diseases
• Review table 52-1 page 854 for comparisons

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Crohns disease Pg 854

• Usually affects terminal portion of ileum
• Cause not known. A genetic predisposition may
  cause it. Also allergic and autoimmune factors
  may cause.
• Exaccerbations seem to correlate with periods of
  stress accompanied by anxiety and depression.
• Inflammation is thru all the layers of the bowel,
  but submucosal most involved

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Crohns Disease

• Affected areas are characterized by hyperemia
  (increased blood supply), edema, and ulcerations.
  Inflamed areas occur randomly and skip lesions
  common.
• Bowel has a cobblestone appearance because of the
  deep ulcerations that form among the edematous
  tissue.
• Fissures which are small cracks fill with pus and
  abscesses form

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Crohns S/S

• Most have abdominal pain, distention, and
  tenderness in lower quadrants of abdomen,
  especially on right side. Pain may or may not be
  associated with eating.
• If eating causes cramping, defecation usually
  relieves the cramping.
• Growth failure occurs in child and adolescent.
  Fever may be present

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Crohns

• Colonoscopy or endoscopy usually not done as may
  perforate bowel and endanger patient
• Causes poor integrity of bowel wall so risk of
  perforation high
• Treatment is supportive, low-residue,
  high-calorie and high protein diet given
• Antidiarrheal meds given sparingly only if known
  no infection due to it predisposes to toxic
  megacolon

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Medication for Treatment
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Ulcerative Colitis Pg 859

• Chronic inflammation mot common in young and
  middle-aged adults
• Most cases are idiopathic and cause not known.
• Due to multiple causitive factors--infection,
  allergy, emotional stress, and autoimmunity.
• Often has other coexisting immune related
  disorders such as spondylitis of the spine,
  migratory arthritis and uveitis
• Colon may dilate and become atonic (lacks motility

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Ulcerative Colitis

• Onset usually abrupt and has severe diarrhea and
  expels blood and mucus along with feces. Has
  cramping which is made worse by eating. has
  diarrhea, anorexia and fatigue. Urgency to
  defecate resulting in incontinent episodes.
• Treatment supportive. Increase calories and
  nutrition may have to be TPN

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Ulcerative Colitis

• Blood transfusions and iron given to correct
  anemia
• Electrolytes and vitamins
• corticosteroids given if it does not respond to
  other treatment.
• Surgery is done when they do not respond to
  medical treatment or a precancerous condition
  (dysplastic tissue), perforation of colon or
  hemorrhage

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Ulcerative Colitis

• Surgery done in two stages and is a cure. Colon
  is removed and a temporary ileostomy done.
  Several weeks later will go back in and attach
  the intestine to the rectum so can defecate thru
  rectum.
• If emergency colectomy done (toxic megacolon or
  perforation) an anastomosis (rejoining the bowel
  ) may not be possible and permanent ileostomy done

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Ulcerative Colitis Nursing Management

• Report any sudden onset of abdominal distention,
  severe pain or fever
• Observe for subtle changes if on steroids because
  these drugs mask inflammatory symptoms
  accompanying complications.
• Refer to section on Crohns for similar problems

http//www.beardmorebros.co.uk/website20pages/uc.
htm
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Appendicitis Pg 861

• Inflammation of a narrow, blind protrusion called
  veriform appendix located at tip of cecum in
  right lower quadrant
• An attack of abdominal pain is most frequent
  symptom. Pain is generalized throughout the
  abdomen or around umbilicus. Later pain localizes
  in right lower quadrant at McBurneys point an
  area midway between umbilicus and right iliac
  crest

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Appendicitis

• Pain is worse when manual pressure near area is
  suddenly released (rebound tenderness)
• Slight or moderate fever, N/V and abdomen may be
  tense and will flex right hip to relieve pressure
• Pain made worse by coughing or walking

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Appendicitis

• Positive Psoas and obturator signs
• Rectal exam will illicit pain
• Abdominal pain (RLQ) with hip extension and
  strait leg raise
• Elderly may only have weakness, anorexia,
  tachycardia,and abdominal distention with little
  pain
• Ruptured appendix serious as causes peritonitis

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Appendicitis

• Pain localizes in right lower quadrant of abdomen
  at McBurneys point, an area midway between the
  umbilicus and the right iliac crest
• Keep NPO, antibiotics given
• Assess vitals and pain to detect early changes in
  symptoms
• Post-op recovery is usually fast. should not lift
  or have unusual exertion for several mo.

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Peritonitis

• In peritonitis, the peritoneum, a serous sac
  lining the abdominal cavity, becomes inflamed.
• Peritonitis may be caused by perforation of a
  peptic ulcer, the bowel, or the appendix
  abdominal trauma, such as gunshot or knife
  wounds ruptured ectopic pregnancy, or infection
  introduced during dialysis.

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Peritonitis Pg. 862

• Severe abdominal pain, distention, tenderness,
  N/V. Fever may be absent initially but as
  infection increases so does the temp.
• Avoids movement of abdomen when breathing as
  causes pain. Bowel sounds absent. Knees may be
  drawn up toward abdomen to lessen the pain. Lack
  of bowel motility and abdomen feels rigid and
  board like

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Intestinal Obstruction Pg. 863

• Complete mechanical obstruction of bowel no gas
  or feces above the obstruction are expelled
  rectally
• They become dehydrated because of vomiting and
  inability to take oral fluids. If obstruction is
  high in GI tract may vomit contents of stomach
  and small intestine

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Intestinal Obstruction

• Depending on the cause when surgery is done a
  temporary or permanent colostomy is done
• A non-mechanical bowel obstruction (Paralytic
  illeus) occurs when there is an absence of normal
  nerve stimulation to muscle fibers of intestine

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Obstruction

• Nausea and abdominal distention. If obstruction
  is high in GI tract usually vomits whatever is in
  stomach and small intestine. Emesis has bile or
  fecal matter. If low then may not have vomiting
• May have one or two BMs after obstructed as BM
  has already moved past obstruction

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Obstruction

• May have severe intermittent cramps
• Sudden, sustained pain, abdominal distention and
  fever are symptoms of perforation
• In non-mechanical obstruction, bowel sounds are
  absent. In a mechanical obstruction, bowel sounds
  are high pitched above the obstruction

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Obstruction

• Intestinal decompression done to prevent or
  relieve distention, cramping, and vomiting and to
  reduce the potential for intestinal rupture with
  peritonitis
• NG tube used if obstruction is high or partial if
  lower then intestinal tube used
• Keep NPO

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Diverticulosis Diverticulitis Pg. 865

• Diverticula are sacs or pouches caused by
  herniation of the mucosa thru a weakened portion
  of the muscular coat of the intestine
• Asymptomatic diverticula are called
  diverticulosis
• If they become inflamed they are called
  diverticulitis
• Common in esophagus and colon, especially the
  sigmoid colon

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• Diverticula become inflamed when fecal material
  becomes trapped within one or more blind pouches.
  The area swells.
• If several pouches involved may cause obstruction
• Abscesses form and diverticula can rupture

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Diverticulitis

• Constipation alternating with diarrhea,
  flatulence, pain and tenderness in left lower
  quadrant, fever and rectal bleeding. Mass may be
  palpated in lower abdomen
• When diverticula bleed stool appears maroon and
  resembles current jelly

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Diverticulitis

• Avoid food that contains seeds, high fiber diet
  supplemented with bran or a Rx for bulk forming
  agent (Metamucil) to avoid constipation.
• When symptoms occur, diet is changed to low
  residue or kept NPO if severe
• May need colostomy until healing occurs and then
  restored 3 to 6 weeks later

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Diverticulitis

• Should avoid laxatives or enemas
• Avoid constipation. Do not suppress the urge to
  defecate
• Drink 8 to 10 glasses of water daily
• Exercise
• call Dr if severe pain or blood in stool

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Abdominal Hernia Pg. 867

• Actually means protrusion of any organ from the
  cavity it normally is in, most commonly refers to
  protrusion of the intestine thru the abdominal
  wall
• Inguinal, femoral, umbilical and incisional are
  most common types
• Inguinal most common in men and umbilical and
  femoral most common in women

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Hernia

• Reducible--protruding structures can be replaced
  in abdominal cavity
• Irreducible or incarcerated hernia--intestine
  cannot be replaced because of edema of protruding
  segment and constriction of the muscle opening.
  Blood supply can be trapped and cut off so
  gangrene occurs. Referred to as a strangulated
  hernia

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Hernia

• Hernia develops when intra-abdominal pressure
  increases such as straining to lift something
  heavy, having a BM, forceful coughing or sneezing
  and intestine moves into a weak area of abdominal
  muscle
• congenital, aging, abd. Surgery and obesity
• Will be small at first and gets larger and
  eventually bowel becomes trapped

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Hernia

• Initially has no symptoms other than swelling on
  abdomen. When instructed to cough or bear down
  the protrusion is more obvious
• sometimes the swelling is painful, but pain
  subsides when hernia is reduced.
• Incarcerated can cause severe pain and may
  strangulate which causes severe abd.pain

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Hernia

• Teach ways to avoid constipation, control a
  cough, and to perform proper body mechanics
• Teach symptoms of incarcerated or strangulated
  hernia
• Explain how to wear a truss, to keep skin dry,
  use cornstarch to absorb moisture.

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Cancer of Colon and Rectum Pg. 868

• Colorectal cancer will have anemia,blood in stool
  and changes in bowel habits
• Approximately 75 occurs in lower sigmoid colon
  and rectum. Risk increases with age.
• Chronic bowel inflammation, low fiber diet and
  high fat diet increases risk. May be genetic.

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Colorectal cancer

• While in situ may change the shape of stool to
  pencil like as it passes by protruding mass
• Chief symptom is change in bowel habits,
  alternating constipation and diarrhea. Occult or
  frank bleeding in stool. May feel dull, vague
  abdominal discomfort. Abdomen feels distended and
  a mass may be palpated in abdomen or rectum. Pain
  is late sign

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• Review box 55-5 for testing stool for occult
  blood page 870

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Hemorrhoids

• Dilated veins outside or inside the anal
  sphincter. Thrombosed hemorrhoids are veins that
  contain clots. Painful but seldom cause bleeding
• External may have few symptoms but may cause
  pain, itching, and soreness of anal area
• Internal may cause bleeding and may be only a few
  drops or enough to cause anemia

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• Review nursing interventions and care plans and
  rest of chapter on your own!!